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How Should Biliary Colic Without Stone Be Treated?

In 5 to 20 percent of patients presenting with biliary-type pain, no stones can be demonstrated on ultrasonography. The care of these patients remains controversial. Most patients undergo multiple investigations seeking the etiology of their symptoms, and many eventually are treated with cholecystectomy despite a failure to demonstrate stones. Brosseuk and Demetrick studied patients who had surgery for acalculous cholecystitis to clarify the diagnosis and optimal treatment of this condition.

They identified 88 patients with acalculous cholecystitis from 755 patients who underwent laparoscopic cholecystectomy in a Can-adian hospital between 1997 and 2001. Th-e-se 88 patients presented with signs and symptoms typical of biliary disease. Other potential causes of their symptoms were excluded by diagnostic investigations. Data were extracted from hospital charts and from a telephone sur--vey of the patients to assess outcomes and pa-tient satisfaction.

The mean age of the 73 women and 15 men was 42 years at the time of surgery, and the average follow-up period was 25 months (range, three to 55 months). Chronic symptoms of recurrent right upper abdominal pain with nausea and vomiting were more common (69 patients) than acute (15 pa-tients) or acute on chronic (four patients). Laparoscopic cholecystectomy alone was performed on 71 pa--t-ients. Of the remainder, 12 also underwent intraoperative cholangiography, and five had an additional procedure. Most patients (78 per-cent) were discharged from the hospital on the same day as the surgery. Readmission was required for 19 pa-tients, and the overall average length of hospital stay was 1.3 days.

Only seven of the removed gallbladders were reported as normal pathologically. The others showed chronic cholecystitis (61 patients) and chronic cholecystitis plus cholelithiasis (10 patients), and 10 had other significant abnormalities. Minor postoperative complications were recorded in 9 per-cent of patients, and major complications occurred in two patients. On the telephone survey, 36 of the 81 patients reported being very satisfied with the surgery, 42 were satisfied, and three were not satisfied.

The authors conclude that acalculous cholecystitis is probably a heterogeneous group of conditions, but that 96 percent of patients reported at least satisfactory relief of symptoms following laparoscopic cholecystectomy. They point out the 11 percent false-negative rate for gallstones based on surgical findings after a negative scan.

anne d. walling, m.d.

Brosseuk D, Demetrick J. Laparoscopic cholecystectomy for symptoms of biliary colic in the absence of gallstones. Am J Surg July 2003;186:1-3.

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